Ask a Revenue Cycle Leader is a new series featuring insights from health system and hospital revenue cycle executives nationwide. Becker’s poses questions on the most pressing issues in healthcare finance — from payer relations and automation to workforce and patient experience. We welcome responses from all revenue cycle, finance and reimbursement leaders.
Question: What is one payer behavior that has changed the most in the past year, and how has your team adapted?
Editor’s note: Responses have been lightly edited for clarity and length.
Adam Gobin. Vice President of Revenue Cycle at Access Medical Clinic (Franklin, Tenn.): The biggest change we’ve seen in the past year is payers leaning harder on prepayment review. Records requests used to be targeted. Now they’re often applied as broad, automated edits, regardless of a provider’s history or documentation quality.
We felt this directly. One of our major payers had a mandatory edit that triggered a medical records request on every claim. That created thousands of touches a month for our team: pulling records, submitting them, tracking them and waiting on claims that should have paid the first time. It also slowed our cash.
Our adaptation was to treat it as a partnership problem, not just a workload problem. We went to the payer and offered to send a sample of patient medical records so they could validate our documentation and coding quality themselves. After they reviewed the sample, they agreed to remove the edit.
That cut thousands of touches per month, sped up payment and freed our team to focus on denial prevention and higher-value follow-up. Just as important, it built trust that we’ve carried into other conversations with that payer.
The lesson for us is that payers are using blanket edits because they lack a reason to trust individual providers. If you give them that reason with transparent data and a willingness to collaborate, many will meet you halfway.
James Hartman. Director of Revenue Cycle at Thorek Memorial Hospital (Chicago): One of the biggest changes I’ve seen is payers moving utilization decisions to third-party vendors and then changing those vendors. CT and MRI authorizations, specialty drugs and post-payment audits now sit with outside review companies. Each runs its own portal and criteria, and rules differ by plan, product and even employer group. A vendor switch or a revised code matrix can change requirements with little notice.
We adapted by using our host system to track authorization requirements by CPT code and payer, then building work queues routed to specific payers. The core problem is that the requirements keep shifting. Each added step or change gives the payer another chance to deny the claim, and organizations that can’t afford automation for every service and payer are left with manual checks.
Paul LePage. Vice President of Revenue Cycle at UC Davis Health (Sacramento, Calif.): The biggest change I’ve seen over the past year is how aggressively payers are challenging medical necessity, even when our teams have secured authorization up front.
We’ve adapted by bringing revenue cycle, utilization management and clinical teams closer together to strengthen documentation and address potential issues before the claim goes out. We’re also tracking payer-specific denial patterns so we can challenge recurring issues with evidence and escalate them beyond individual appeals.
My expectation is that we use every denial to inform prevention, because repeatedly winning the same argument is still an expensive way to get paid.
Next question: What is one creative solution your team found to a payer problem, and what was the result? If you are interested in responding, please send responses to Andrew Cass at acass@beckershealthcare.com.
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